General Examination – Part II

 General overview:
 Conscious level
 Appearance
 Body built
 Colours (complexion)
 Decubitus
 Facial expressions
 Vital signs:
 Pulse BPTR
 Blood pressure
 Respiratory rate
 Temperature
 Systemic overview:
 Head & neck
 Upper limbs (hands)
 Lower limbs (feet)

1- Conscious level:
 Alertness, orientation (time, place & person), mood (= emotional state,
depression, euphoria), memory (near & far events), intelligence (IQ test, the
patient & the doctor can understand each other) and behaviour.
 Normally: The patient is fully conscious, oriented to time, place & persons,
cooperative and of average mood, memory & intelligence.
 Conscious level is impaired (disturbed) → confusion/ coma in neurological
disorders (cerebrovascular stroke, meningitis, Alzheimer disease) and major
organ failure (liver, kidney, respiratory failure)

2- Appearance:
 Normally: looks well
 Abnormally: looks ill
 Ill & toxic: in chronic infection (tuberculosis, infective endocarditis,
thyrotoxicosis)
 Ill & cachectic: malignancy

3- Body built: (Anthropometric measures)

 Body weight: assessment for obesity
 Body mass index (BMI)
 BMI = Weight (Kg)/ Height (m2)
  Example: if the patient weight = 70 kg, his height 170 cm (1.7 m), his
BMI = 70/(1.7)2 = 24.22 Kg/m2
 Classification of body weight according to BMI:
 Average body weight: 18.5 – 24.9 kg/m2
 Underweight: < 18.5 kg/m2
 Overweight: 25 – 29.9 kg/m2
 Obesity ≥ 30 kg/m2
o Obesity class I: 30-34.9 kg/m2
o Obesity class II: 35-39.9 kg/m2
o Obesity class III (morbid obesity) ≥ 40 kg/m2
 Skin fold thickness: the thickness of skin folds in:
 Lateral aspect of the arm: 0.9 – 1.1 cm.
 Abdomen = 1.5 cm.
 Buttocks = 1.5-2.5 cm.
 Waist circumference (WC):
 A better measurement for obesity than BMI
 Measured by wrapping a tape around the abdomen midway between
two lines, a line crossing both costal margins & a line crossing both
iliac crests.
 Normal WC= 80-88 cm in men, 94-102 cm in women
 Obesity: > 88 cm in men & > 102 cm in women

 Body height:
 Height: the distance between the occiput to the heels in the standing upright
position
 Span: the distance between the tips of the fingers in the outstretched hands
 Normally: the body height is nearly equal to the span (proportionate)
  Upper body segment: the distance from the occiput till the symphysis pubis
 Lower body segment: the distance from the symphysis pubis till the floor
 Normally the upper body segment equals the lower body segment
 Short stature (dwarfism) causes: pituitary gland hypofunction,
hypothyroidism in children (cretinism)
 Tall stature: as in pituitary gland hyperfunction in children ((gigantism)

Short stature Gigantism

4- Complexion (Colours):
 Pallor
 Jaundice PPJC
 Cyanosis
 Pigmentation
  Pallor: decreased visibility of oxyhemoglobin in blood vessels
 Sites of examination:
 Inner aspect of lips.
 Tongue
 Skin of the face.
 Nails.
 Inferior fornix of the conjunctiva
 Palmar creases
 Causes of pallor:
 Anemia.
 Shock
 Toxemia e.g. infective endocarditis.
 Edema of the face e.g. nephrotic syndrome, myxedema

 Jaundice: yellowish discoloration of skin & mucous membranes due to

increased serum bilirubin > 3 mg/dl
 Sites of examination:
 Soft palate
 Sclera of the eye
 Skin
 Method of examination: should be examined in daylight, ask the patient to
look upward while you are holding his lower eyelid downward to look to the
sclera.
 Types of jaundice:

Type of jaundice Causes Color of Urine color Stool color

jaundice
Hepatocellular Viral hepatitis Orange yellow Dark Pale
Liver cirrhosis
Liver failure
Haemolytic Haemolytic Lemon yellow Pale Dark
anemia
Obstructive Biliary tract Olive green Dark Pale
obstruction
(stones/
tumors)
 Jaundice

 Cyanosis: bluish discoloration of skin & mucous membranes due to

increased reduced haemoglobin > 5 gm/dl.
 Sites of examination: nails, lips, tongue, nose, lobule of the ear
 Types of cyanosis:

Type of Central cyanosis Peripheral cyanosis

cyanosis
Mechanism Impaired blood oxygenation in Blood stagnation in peripheral
heart &/or lungs vessels or decreased blood flow
to the peripheral tissues
Causes - Heart: cyanotic heart diseases - Cold exposure
- Lung disease: respiratory - Arterial &/or venous
failure, COPD thrombosis in the limbs
- Asphyxia - Shock
- High altitude - Raynaud’s phenomenon
Sites - Nails - Nails
- Lips - Lips
- Nose - Nose
- Ear lobule - Ear lobule
- Tongue - Tongue is normal

Hands - Warm - Cold

Warming - No effect - Improves cyanosis
hands
Oxygen - Improve cyanosis - No effect
therapy
 Cyanosis
 Hyperpigmentation:
 Generalized: due to liver failure, renal failure, Addison’s disease,
hemochromatosis
 Localized (in the face only): due to mitral stenosis, systemic lupus
erythromatosis, pregnancy

Hyperpigmentation

4- Decubitus:
 It is the position of the patient in bed
 Normally, the patient lies flat & comfortable in bed without dyspnea or pain
 Abnormal positions:
 Orthopnea:- Semi setting position, due to left-side heart failure,
COPD, massive ascites, morbid obesity
 Squatting position: In Fallot's tetralogy (cyanotic congenital heart
disease)
 The prayer’s position: pericardial effusion, pancreatitis
 Lateral Position in chest diseases: pleurisy, lung abscess
 Dorsal position (flexed knees & hips) with abdominal rigidity:
peritonitis, appendicitis
 Squatting position Prayer position

5- Abnormal facial expression:

 Ape facies: acromegaly
 Moon face: Cushing’s disease
 Mongloid facies: Thalassemia
 Malar rash: SLE
 Mask face: Parkinson’s disease

Ape facies Moon face Mongloid facies

Malar rash
 General Examination – Part III

6- Vital Signs:

A- Pulse:

 Definition: A pressure wave transmitted from the left ventricle contraction

to the arteries through the Aorta.
 Examination:
 Encircle the wrist & palpate the radial artery by the middle 3 fingers (index &
ring fingers for slight compression & the middle Finger for palpation)
 If pulse is regular, you may count in 30 sec. and multiply by 2 ,,, or in 15 sec.
and multiply by 4.
 Comment on:
1. Rate
2. Rhythm
3. Volume
4. Equality ( of volume) on both sides.
5. Special character.
6. Condition of the blood vessels
7. Peripheral pulsations.
 Pulse Rate: it is either,
 Normal rate: 60 - 100 beats / minute (BPM)
 Tachycardia: increased heart rate > 100 bpm
 Bradycardia: decreased heart rate < 60 bpm

 Pulse Rhythm: you should know it first before counting the rate. It is either
regular or irregular

 Causes of irregular pulse: Atrial fibrillation (AF), extrasystole, ventricular

fibrillation

 Pulse Volume: it is the amplitude of pulse pressure (SBP - DBP)

 Normally: 20 – 60 mmHg.
 Examination: observing the movement of the palpating finger produced by the
pulse wave.
 Big pulse pressure: Pulse pressure > 1/2 systolic blood pressure (SBP)
&/or or > DBP.
 Causes of big pulse pressure: are the causes of hyperdynamic circulation
 H: Hypoxia – Hyperthyroidism – Hepatic Failure – Hyperthermia
 B: Pregnancy – Beri Beri (Vitamin B1 deficiency) – Paget's disease
of bones
 A: Anemia – Arterio-venous (AV) fistula – Aortic regurge

 Equality (of pulse volume) on both sides:

 Both radial arteries must be examined at the same time for equality as regard
volume.

 Causes of unequal pulse:

 Compression from outside: cervical rib, Pancoast tumors, enlarged
cervical lymph nodes
 Vessel wall abnormalities: vasculitis, aortic coarctation
 Lumen obstruction: thrombosis, embolism
 Special characters:
 Water hammer pulse (collapsing pulse):
 Definition: Sharp ascending and sharp descending with high amplitude
(e.g. BP: 160/50)
 Causes: the same of big pulse volume

 Plateau pulse:
 Definition: slow ascending and slow descending with low amplitude.
 Causes: Aortic stenosis, left ventricular failure (LVF)

 Pulsus paradoxus:
 Definition: exaggerated drop of the systolic blood pressure during
inspiration (more than 10 mm Hg)
 Causes: pericardial tamponade, COPD, congestive heart failure
 Detection: Measure B.P. during inspiration & during expiration.

 Pulsus deficit:
 Definition: Pulse rate at the apex of the heart is more than the rate of
the radial pulse
 Mechanism: Contraction of an empty ventricle (so some weak beats
are unable to reach the radial artery).
 Causes: A.F >10 bpm, multiple extrasystoles < 10 bpm.

 Pulsus bisferiens = bifid pulse =

 Definition: double beaks of the pulse wave
 Examination: Best seen & felt at carotid artery
 Causes: severe aortic regurge, hypertrophic obstructive
cardiomyopathy (HOCM)
 Pulsus alternans:
 Definition: Alternating strong & weak pulse beats
 Causes: Severe Left Ventricular Failure.
 Detection: palpation of pulse volume or by sphygmomanometer

 Vascular wall condition:

 Examined by Rolling maneuver: distal and proximal occlusion of small
segment of the radial artery by the index and ring fingers, then rolling of the
artery with the middle finger.
 Normally: the arterial wall is not felt
 Causes of palpable arterial wall: Atherosclerosis, Vasculitis e.g: polyarteritis
nodosa

 Peripheral pulsations: examine for other peripheral arterial pulsations

Radio-femoral delay:

- Abnormal finding in which the pulse of the femoral artery is weaker &
delayed in comparison to the radial artery when they are felt simultaneously.
- Caused by Coarctation of aorta

Example of the pulse comment:-

The patient’s pulse is 75 beat/min., regular, average volume, equal on both sides,
no special character, the blood vessel walls are normal and not felt with palpable
pulsations of dorsalis pedis artery

B- Temperature:
 Measurement: Using a mercury thermometer

 Oral temperature:
 Insert the thermometer under the tongue with closed lips for 3
minutes.
 Normal oral temperature= 36.5 – 37.2 °C.
 Rectal temperature:
 Insert the thermometer in the rectum through the anal canal for 2
minutes (subtract 0.5 o C of the reading).
 Indicated in infants, comatosed patients, painful oral lesions.
 Axillary temperature:
 Insert the thermometer in axilla for 3 minutes (add 0.5o C to the
reading).
 Abnormal body temperature:
 Fever: body temperature > 37.2 °C.
 Hypothermia: body temperature ≤ 35 °C.
 Hyperthermia: body temperature > 41 °C.
 Types of Fever:
 Continuous fever:
 Definition: Fever with body temperature fluctuation <1 °C &
always body temperature above the normal base line.
 Causes: Gram negative infections, CNS damage (hemorrhage,
infarction)

 Remittent fever:
 Definition: fever with body temperature fluctuation >1 °C and
temperature is always > the normal base line.
 Causes: Viral infections, Tuberculosis (TB)

 Intermittent (Hectic) fever:

 Definition: fever with body temperature fluctuation >1 °C and
temperature may reach the normal base line.
 Causes: Abscess, malaria

 Relapsing (cyclic, periodic) fever:

 Definition: Days of fever and days of normal body temperature
 Causes: lymphoma, brucellosis, familial mediterranean fever
(FMF)
 Temperature – Pulse relationship:
 Synchronized relationship: Each 1°C rise in body temperature → ↑
pulse rate 10 beats/minute
 Non-synchronized relationship:
 Relative tachycardia: the increase in pulse rate is more than
expected for body temperature e.g: Myocarditis
 Relative bradycardia: the increase in pulse rate is less than
expected for body temperature e.g: typhoid fever

C- Blood pressure:
 Definition: Pressure of blood on the arterial wall during contraction (systole) &
relaxation (diastole) of the left ventricle.
 Blood pressure = Systolic blood pressure (SBP)/ diastolic blood pressure (DBP)
 BP = SBP/DBP
 Normally: SBP = 100 - < 140 mmHg, DBP = 60 - < 90 mmHg
 Measurement of BP.:
 Direct: direct intra-arterial measurement using specific catheters.
 Indirect: by sphygmomanometer (palpatory, & Auscultatory methods)
 BP is usually equal in both Right & left ULs: difference is < 10mm Hg
 Normally, BP in LL > UL by less than 20 mm Hg.
 Technique of measurement of BP:
 Under complete physical & mental rest of the patient for at least 5 minutes,
with no tight clothes.
 Place the cuff of the sphygmomanometer on the patient’s arm at the level of
the heart. Not tight nor loose.
 The inflated bag (the bladder of the cuff) should be on the medial side of the
arm, with its lower border is at least 2 cm above the cubital fossa.
 Palpatory method: palpate the radial artery of the same arm, inflate the cuff
bladder till the radial pulse disappears, then deflate till the pulse reappear (the
point at which the pulse re-appear, this is the estimated SBP by Palpatory
method)
 Auscultatory method:
 Place the stethoscope over the brachial artery in the cubital fossa
medial to the Biceps tendon (Never place the stethoscope under the
cuff of the sphygmomanometer)
 Inflate the cuff again to a point 30 mmHg above the SBP estimated by
Palpatory method … you will hear no sounds above SBP point.
 Deflate the cuff gradually (2- 5 mmHg/second), till:
  You clearly hear the 1st sound of brachial pulsation (SBP)
 Deflate till the sound disappear again (DBP)

 Korotkoff sounds (Phases): the sounds heard by stethoscope during BP

measurement
 1st phase (SBP): the first sharp tapping sound that appears clearly with
cuff deflation, due to opening of the occluded brachial artery
 2nd phase: soft, swishing sound due to increased blood flow into the
artery
 3rd phase: sharp & louder sound than SBP due to larger amount of
blood flowing into the brachial artery.
 4th phase: sudden marked decrease in sound intensity → muffled &
faint sound.
 5th phase (DBP): complete disappearance of all sounds.
 In some hypertensive patients, sounds may disappear completely between
phases 2 & 3 (auscultatory gap)
 BP measurement in the LL:
 Patient is lying in prone position.
 Place the cuff around the lower 1/3 of the thigh above popliteal fossa.
 Auscultate (or palpate) popliteal artery.
 Continues as in U.L.

 Hill’s phenomena: Blood pressure in lower limbs > blood pressure in upper
limbs by less than 20 mmHg, which is normal.
 Hill’s sign: blood pressure in lower limb > blood pressure in upper limb by >
60 mmHg, in aortic regurge.
 Reversal of Hill’s phenomena: blood pressure in lower limb < blood pressure
in upper limb, in coarctation of aorta.
 In postural hypotension (orthostatic hypotension = orthostatic syncope):
exaggerated fall of SBP (& DBP) more than 20 mmHg in standing position
than sitting or recumbent position.
 Uses of sphygmomanometer:
1. Measurement of B.P.
2. Determination of pulse pressure (SBP-DBP)
3. Detection of pulsus alternans
4. Detection of pulsus paradoxus
5. Detection of unequality of pulse in both sides (different blood pressure in Rt.
& Lt limb).
6. Diagnostic signs: Hill’s sign & reversal of Hill’s sign
7. Can be used as a tourniquet to stop bleeding till arrival to the hospital.
8. Diagnostic tests:
 Hess test: Capillary fragility test
 Trousseau’s test: diagnosis of latent tetany
 Walker's test: diagnosis of Myasthenia gravis.

D- Respiratory rate: Tachypnea>20

 Examination:
 The patient is in the supine position Bardypnea<12
 Place a light object on the chest wall to notice its movements e,g: pen,
watch, the patient’s hand
 Try to distract the patient attention e.g: hold his hand as if you are
counting the pulse
 Count the respiratory rate as cycles in one minute (1 inspiration + 1
expiration = one cycle)
 Normal respiratory rate: 12 - 20 cycles per min., with pulse rate / RR. = 4 / 1
 Rhythm: regular.
 Depth: average, not deep nor shallow.
 Type: normally; abdomino-thoracic in males & thoraco-abdominal in females.